Fkc E 11 Street - Anniston

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 50873 Based on observation, interview, and facility policy review, the facility failed to ensure five (Registered Nurse [RN] #3 and RN #5 and Patient Care Technicians [PCTs] #8, #9, and #10) of six staff members disinfected items prior to removing them from dialysis treatment stations. Specifically, staff were observed to move a sharps container, biohazard bin, and trash can from treatment stations to a common area in the treatment room or to another treatment station without disinfecting the items. Findings included: A facility policy titled, “Cleaning and Disinfecting the Dialysis Station,” published 09/02/2025, indicated, “The dialysis station could become contaminated with blood and other body fluids during treatment. After use, any non-disposable equipment and supplies brought in the dialysis station (ex. Stethoscope) must be disinfected with a 1:100 bleach or EPA registered disinfectant before being removed from the dialysis station.” During an observation on 01/06/2026 at 10:39 AM, PCT #9 entered Treatment Station #4 to assist with discontinuing dialysis for a patient. PCT #9 was observed to bring a sharps container, biohazard bin, and trash can into the treatment station approximately two feet from the patient, where staff disposed of used items. The observation revealed PCT #9 then removed the sharps container, biohazard bin, and trash can from the treatment station without disinfecting them and placed them in an area in the center of the room where the treatment stations were located. On 01/06/2026 at 10:56 AM, PCT #8 was observed to remove the biohazard bin from Treatment Station #7 and place it in the center area without disinfecting the container. On 01/06/2026 at 11:16 AM, PCT #10 was observed to remove the sharps container from Treatment Station #19 and place it in the common area in front of nurses’ station, across from Treatment Station #1 without disinfecting the container. On 01/06/2026 at 11:19 AM, RN #5 was observed initiating treatment in Treatment Station #14. The RN was observed to remove the sharps container and trash can from Treatment Station #14 and take them to Treatment Station #17 without disinfecting the containers. On 01/06/2026 at 12:22 PM, PCT #10 was observed to remove the biohazard bin from Treatment Station #2 and move it to the common area in front of the nurses’ station without disinfecting the container. On 01/06/2026 at 12:29 PM, RN #3 was observed to remove the trash bin and the sharps container from Treatment Station #2 and placed them in the common area in front of the nurse station without disinfecting the containers. On 01/06/2026 at 3:10 PM, PCT #9 stated that biohazard bins and sharps containers only got wiped down when they were soiled. The PCT stated, “We [staff] pull them over, so we aren’t walking across the room with sharps.” The PCT stated that when taking any unused supplies from the treatment station they should be thrown away, wiped down, or put in the sharps container. The PCT revealed that the biohazard and sharps containers should have been wiped down when removed from a treatment station. During an interview on 01/06/2026 at 3:30 PM, RN #3 revealed that biohazard bins and sharps containers should be wiped down when taken out of a treatment station. The RN revealed that they forgot to perform the task that day. During an interview on 01/07/2026, RN #5 revealed that on 01/06/2026 the RN did not wipe down the sharps containers and biohazard bins when removing them from the treatment station. The RN stated that in the clinic where the RN completed their training, the bins were located closer to the treatment station, so the staff did not have to bring them into the treatment station. On 01/06/2026 at 4:00 PM, the Charge Nurse (CN) stated that she felt staff were uncertain whether the biohazard and sharps containers only needed to be wiped down when they were soiled. The CN confirmed the facility’s expectation was that the bins be disinfected when coming out of the treatment station. On 01/09/2026 at 1:04 PM, the Medical Director confirmed the facility’s expectation was that items brought into the treatment station be disinfected or disposed of when taken out of the treatment station.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 50873 Based on record review, interview, and facility document and policy review, the facility failed to provide necessary care to manage the volume status, including monitoring and management of vital signs for seven (Patients #1, #2, #3, #4, #5, #6, and #7) of seven sampled patients. Findings included: A facility policy titled, “Patient Assessment and Monitoring,” published 05/01/2023, indicated that staff should “Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations” during treatment. The policy also revealed, “Report to the nurse: Systolic blood pressures [top number of a blood pressure reading] greater than 180 mm/Hg [millimeters of mercury], Diastolic blood pressure [bottom number of a blood pressure reading] greater than 100 mm/Hg, Blood pressure less than or equal to 100 mm/Hg systolic.” The policy also revealed, “Report to the nurse patients whose heart rates have dropped below 60 [beats per minute (bpm)], risen above 100 or become irregular.” A facility policy titled, “Hypertension,” published 09/07/2021, revealed, “Follow the steps below to address hypertension: 2. The RN [registered nurse] will assess the patient and determine if further nursing interventions are needed. 3. If hypertension is related to hypervolemia, decrease EDW [estimated dry weight]: Follow CMAB [unknown acronym] Fluid Management algorithm or notify physician for possible estimated dry weight adjustment outside of algorithm parameters. 4. If hypertension is not related to hypervolemia, notify the physician for additional orders/interventions. 5. Document in patient’s treatment record.” 1. A “Treatment Sheet” for Patient #1 dated 12/22/2025 revealed Registered Nurse (RN) #3 documented that the patient’s blood pressure was 208/110 mm/Hg while sitting and 202/109 mm/Hg while standing at 6:11 AM and 190/115 mm/Hg at 6:24 AM, RN #2 documented the patient’s blood pressure was 183/93 mm/Hg at 7:02 AM, and Patient Care Technician (PCT) #9 documented the patient’s blood pressure was 181/96 mm/Hg at 7:38 AM. There was no documented evidence that the PCT notified an RN or that an RN notified the provider of the patient’s out-of-range blood pressure readings. A “Treatment Sheet” for Patient #1 dated 12/24/2025 revealed PCT #6 documented that the patient’s blood pressure was 182/92 mm/Hg at 8:30 AM, and PCT #11 documented a blood pressure reading of 181/91 mm/Hg at 10:01 AM for the patient. There was no documented evidence that the PCTs notified an RN of the patient’s out-of-range blood pressure readings. A “Treatment Sheet” for Patient #1 dated 01/03/2026 revealed PCT #8 documented that the patient’s blood pressure was 194/106 mm/Hg at 7:06 AM and 186/100 mm/Hg at 8:33 AM; PCT #11 documented the patient’s blood pressure was 190/103 mm/Hg at 8:04 AM; PCT #15 documented the patient’s blood pressure was 192/99 mm/Hg at 9:03 AM, 192/102 mm/Hg at 9:34 AM, and 182/103 mm/Hg at 10:17 AM; RN #3 documented the patient’s blood pressure was 183/99 mm/Hg at 6:30 AM; and RN #5 documented the patient’s blood pressure was 197/109 mm/Hg at 7:30 AM. There was no documented evidence of the PCTs’ notification to an RN or an RN notification to the provider of the patient’s elevated blood pressure readings. 2. A “Treatment Sheet” for Patient #2 dated 12/20/2025 revealed that Patient Care Technician (PCT) #6 documented that the patient’s heart rate was 49 bpm at 8:29 AM, and PCT #10 documented the patient’s heart rate was 104 bpm at 9:30 AM. There was no documented evidence that the PCTs’ notified a registered nurse (RN) that the patient’s heart rate was out-of-range. A “Treatment Sheet” for Patient #2 dated 12/24/2025 revealed that PCT #11 documented the patient’s blood pressure was 91/59 mm/Hg at 6:30 AM, 92/59 mm/Hg at 8:04 AM, 92/47 mm/Hg at 9:00 AM, 85/51 mm/Hg at 10:00 AM, and 83/54 mm/Hg at 10:14 AM. There was no documented evidence that the PCT notified an RN that the patient’s systolic blood pressure was less than 100 mm/Hg. A “Treatment Sheet” for Patient #2 dated 12/27/2025 revealed that PCT #7 documented the patient’s blood pressure was 96/53 mm/Hg at 9:30 AM and 97/67 mm/Hg at 10:00 AM. There was no documented evidence that the PCT notified an RN of the out-of-range vital signs. A “Treatment Sheet” for Patient #2 dated 12/31/2025 revealed that PCT #8 documented that the patient’s blood pressure was 97/57 mm/Hg at 6:36 AM. There was no documented evidence that the PCT notified an RN that the patient’s systolic blood pressure was less than 100 mm/Hg. 3. A “Treatment Sheet” for Patient #3 dated 12/11/2025 revealed Registered Nurse (RN) #2 documented that the patient’s blood pressure was 168/106 mm/Hg while sitting and 158/119 mm/Hg while standing at 6:51AM, 182/126 mm/Hg at 7:14 AM, and 245/162 mm/Hg while sitting and 232/135 mm/Hg while standing at 11:10 AM. The Treatment Sheet revealed Patient Care Technician (PCT) #11 documented Patient #3’s blood pressure was 187/120 mm/Hg at 8:00 AM; PCT #14 documented the patient’s blood pressure was 180/112 mm/Hg at 8:37 AM, 188/108 mm/Hg at 9:03 AM, and 245/162 mm/Hg at 11:06 AM; and PCT #7 documented Patient #3’s blood pressure was 183/107 mm/Hg at 9:37 AM and 197/130 mm/Hg at 10:05 AM. There was no documented evidence that the PCTs notified an RN or that an RN notified the patient’s provider that the patient’s blood pressure was out-of-range. A “Treatment Sheet” for Patient #3 dated 12/16/2025 at 12:40 PM, revealed PCT #8 documented that the patient’s blood pressure was 195/133 mm/Hg while sitting and 222/133 mm/Hg while standing and the patient’s heart rate was 107 bpm. The Treatment Sheet revealed PCT #14 documented that the patient’s blood pressure was 194/124 mm/Hg at 1:05 PM, and PCT #11 documented 211/128 mm/Hg at 2:00 PM. There was no documented evidence that the PCTs notified an RN of patient’s out-of-range vital signs. A “Treatment Sheet” for Patient #3 dated 12/18/2025 revealed RN #5 documented the patient’s blood pressure was 198/123 mm/Hg at 12:41 PM, 250/143 mm/Hg at 2:00 PM, 241/111 mm/Hg at 4:12 PM, and 241/111 mm/Hg while sitting and 243/148 mm/Hg while standing at 4:14 PM; RN #16 documented the patient’s blood pressure was 228/134 mm/Hg at 1:34 PM; PCT #7 documented the patient’s blood pressure was 193/116 mm/Hg while sitting and 225/133 mm/Hg while standing and the heart rate was 110 bpm at 12:30 PM; and PCT documented Patient #3’s blood pressure was 233/122 mm/Hg and a heart rate was 107 bpm at 1:05 PM and the blood pressure was 233/142 mm/Hg at 4:03 PM. There was no documented evidence that the PCTs’ notified an RN or that an RN notified the provider that the patient’s vital signs were out-of-range. A “Treatment Sheet” for Patient #3 dated 12/20/2025 revealed RN #5 documented the patient’s blood pressure was 198/129 mm/Hg at 12:24 PM, 244/135 mm/Hg at 4:00 PM, and 233/125 mm/Hg at 4:26 PM; PCT #6 documented the patient’s blood pressure was 187/118 mm/Hg at 12:30 PM, blood pressure was 220/135 mm/Hg and heart rate was 116 bpm at 1:00 PM, and blood pressure was 215/119 mm/Hg at 1:30 PM; and PCT #10 documented the patient’s blood pressure was 225/126 mm/Hg at 2:00 PM. The Treatment Sheet revealed PCT #11 documented that Patient #3’s blood pressure was 211/131 mm/Hg at 2:30 PM, 223/126 mm/Hg at 3:00 PM, 219/133 mm/Hg at 3:30 PM and 230/147 mm/Hg while sitting and 241/139 mm/Hg while standing with a heart rate of 110 bpm at 4:39 PM. There was no documented evidence that the PCTs notified an RN or that an RN notified the provider that the patient’s vital signs were out-of-range. A “Treatment Sheet” for Patient #3 dated 12/22/2025 revealed RN #2 documented the patient’s blood pressure was 181/118 mm/Hg at 1:00 PM; and RN #3 documented that the patient’s blood pressure was 225/127 mm/Hg and heart rate was 109 bpm at 4:00 PM and at 4:02 PM, the patient’s blood pressure was 221/122 mm/Hg while sitting and 221/124 mm/Hg while standing. The note revealed PCT #9 documented that the patient’s blood pressure was 201/120 mm/Hg at 1:30 PM, blood pressure was 217/133 mm/Hg and heart rate was 104 bpm at 2:00 PM, and the blood pressure was 211/128 mm/Hg at 2:30 PM and 226/132 mm/Hg at 3:03 PM; PCT #6 documented the patient’s blood pressure was 166/110 mm/Hg at 12:55 PM; and PCT #12 documented the blood pressure was 211/140 mm/Hg at 3:35 PM. There was no documented evidence that the PCTs notified an RN or that an RN notified the provider that the patient’s vital signs were out-of-range. A “Treatment Sheet” for Patient #3 dated 12/29/2025 revealed RN #2 documented the patient’s blood pressure was 201/124 mm/Hg at 12:40 PM, 187/170 mm/Hg at 12:51 PM, and 205/126 mm/Hg at 1:00 PM; RN #4 documented the patient’s blood pressure was 218/128 mm/Hg at 3:55 PM, 219/124 mm/Hg while sitting and 187/113 mm/Hg while standing at 3:56 PM; PCT #9 documented the patient’s blood pressure was 243/134 mm/Hg at 1:30 PM, 215/126 mm/Hg at 2:00 PM, 196/112 mm/Hg at 2:30 PM, and 213/110 mm/Hg at 3:00 PM; and PCT #10 documented the patient’s blood pressure was 225/129 mm/Hg at 3:30 PM. There was no documented evidence that the PCTs notified an RN or that an RN notified the provider of the patient’s out-of-range blood pressure. 4. A “Treatment Sheet” for Patient #4 dated 12/26/2025 revealed that Patient Care Technician (PCT) #15 documented the patient’s heart rate was 59 bpm at 12:22 PM and 49 bpm at 11:46 AM, and PCT #8 documented the patient’s heart rate was 51 bpm at 4:04 PM and 58 bpm at 4:25 PM. There was no documented evidence that the PCT notified a registered nurse (RN) that the patient’s heart rate was out-of-range. A “Treatment Sheet” for Patient #4 dated 12/28/2025 revealed that PCT #15 documented the patient’s heart rate was 50 bpm at 1:13 PM, PCT #8 documented 57 bpm at 1:34 PM, and PCT #9 documented 50 bpm at 3:07 PM. There was no documented evidence that the PCTs notified an RN that the patient’s heart rate was out-of-range. A “Treatment Sheet” for Patient #4 dated 12/30/2025 revealed that PCT #10 documented that the patient’s heart rate was 49 bpm at 12:00 PM and 49 bpm at 12:11 PM. There was no documented evidence that the PCT notified an RN that the patient’s heart rate was out-of-range. A “Treatment Sheet” for Patient #4 dated 01/02/2026 revealed PCT #7 documented the patient’s heart rate was 51 bpm at 2:30 PM and 48 bpm at 3:04 PM and PCT #8 documented the patient’s heart rate was 50 bpm at 3:42 PM and 54 bpm at 4:26 PM on 01/02/2026. There was no documented evidence that the PCTs notified an RN that the patient’s vital signs were out-of-range. A “Treatment Sheet” for Patient #4 dated 01/05/2026 revealed PCT #14 documented that the patient’s heart rate was 53 bpm at 12:25 PM and 55 bpm at 12:36 PM; PCT #9 documented 53 bpm at 3:30 PM; and PCT #10 documented 49 bpm at 1:00 PM, 51 bpm at 1:30 PM, 49 bpm at 2:00 PM, 55 bpm at 2:30 PM, and 56 bpm at 3:00 PM. There was no documented evidence that the PCTs notified an RN that the patient’s vital signs were out-of-range. 5. A “Treatment Sheet” for Patient #5 dated 12/23/2025 revealed Patient Care Technician (PCT) #11 documented the patient’s blood pressure was 227/77 mm/Hg while sitting and 225/89 while standing and the heart rate was 103 bpm at 6:11 AM, blood pressure was 182/84 mm/Hg at 6:19 AM, and the patient’s heart rate was 51 bpm at 7:09 AM, 51 bpm at 9:03 AM, and 47 bpm at 10:00 AM; and PCT #14 documented the patient’s heart rate was 46 bpm at 7:31 AM. There was no documented evidence that the PCTs notified a registered nurse (RN) of the out-of-range vital signs. A “Treatment Sheet” for Patient #5 dated 12/26/2025 revealed PCT #14 documented the patient’s blood pressure was 215/94 mm/Hg while sitting and 262/115 mm/Hg while standing and the patient’s heart rate was 114 bpm at 6:14 AM, blood pressure was193/77 mm/Hg at 6:30 AM and 184/82 mm/Hg at 7:02 AM, heart rate was 55 bpm at 8:03 AM and 47 bpm at 10:04 AM; and PCT #15 documented the patient’s heart rate was 48 bpm at 8:34 AM. There was no documented evidence that the PCT notified an RN of the out-of-range vital signs. A “Treatment Sheet” for Patient #5 dated 12/28/2025 revealed PCT #6 documented the patient’s blood pressure was 189/73 mm/Hg while sitting and 217/87 mm/Hg while standing at 6:07 AM, 193/79 mm/Hg at 6:19 AM, 207/90 mm/Hg at 6:30 AM, 197/87 mm/Hg at 7:00 AM, 196/75 mm/Hg at 7:30 AM, the heart rate was 49 bpm at 8:30 AM, 50 bpm at 9:00 AM, 47 bpm at 9:30 AM, 46 bpm at 10:05 AM, and 44 bpm at 10:21 AM; and PCT #15 documented the patient’s heart rate was 44 bpm at 8:05 AM. There was no documented evidence that the PCTs notified an RN of the out-of-range vital signs. A “Treatment Sheet” for Patient #5 dated 01/02/2026 revealed PCT #11 documented the patient’s blood pressure was 177/119 mm/Hg at 6:33 AM, heart rate was 53 bpm at 8:37 AM, heart rate was 52 bpm at 9:03 AM, heart rate was 53 mm/Hg at 9:41 AM, and heart rate was 46 bpm at 10:25 AM. There was no documented evidence that the PCT notified an RN of the out-of-range vital signs. A “Treatment Sheet” for Patient #5 dated 01/05/2026 revealed PCT #7 documented the patient’s blood pressure was 194/88 mm/Hg at 6:18 AM, 191/85 mm/Hg at 7:03 AM, and 195/92 mm/Hg at 10:10 AM; and PCT #10 documented the patient’s blood pressure was 208/94 mm/Hg at 6:30 AM. There was no documented evidence that the PCTs notified an RN of the out-of-range vital signs. 6. A “Treatment Sheet” for Patient #6 dated 12/26/2025 revealed that Patient Care Technician (PCT) #9 documented that the patient’s heart rate was 49 bpm at 1:03 PM. There was no documented evidence that the PCT notified a registered nurse (RN) of the out-of-range vital signs. A “Treatment Sheet” for Patient #6 dated 12/29/2025 revealed that PCT #10 documented the patient’s blood pressure was 94/57 mm/Hg and the heart rate was 57 bpm at 2:07 PM and 92/52 mm/Hg at 4:03 PM. There was no documented evidence that the PCT notified a registered nurse (RN) of the out-of-range vital signs. A “Treatment Sheet” for Patient #6 dated 12/31/2025 revealed PCT #17 documented the patient’s heart rate was 45 bpm at 2:00 PM. There was no documented evidence that the PCT notified a registered nurse (RN) of the out-of-range vital signs. A “Treatment Sheet” for Patient #6 dated 01/02/2026 revealed PCT #7 documented the patient’s heart rate was 57 bpm at 3:05 PM. There was no documented evidence that the PCT notified a registered nurse (RN) of the out-of-range vital signs. 7. A “Treatment Sheet” for Patient #7 dated 12/02/2025 revealed that Patient Care Technician (PCT) #9 documented the patient’s blood pressure was 225/120 mm/Hg at 7:30 AM, 226/121 mm/Hg at 8:00 AM, 203/110 mm/Hg at 9:30 AM, 194/100 mm/Hg at 10:03 AM, 204/105 mm/Hg at 10:30 AM, 215/96 mm/Hg at 11:01 AM, and 194/104 mm/Hg at 11:34 AM; and PCT #14 documented the patient’s blood pressure was 231/144 mm/Hg at 8:39 AM. There was no documented evidence that the PCTs notified an RN of the patient’s out-of-range blood pressures. A “Treatment Sheet” for Patient #7 dated 12/06/2025 revealed that PCT #9 documented the patient’s blood pressure was 195/92 mm/Hg at 7:36 AM, 188/98 mm/Hg at 8:02 AM, 183/99 mm/Hg at 8:30 AM, 188/91 mm/Hg at 9:36 AM, 197/104 mm/Hg at 10:00 AM, 193/102 mm/Hg at 10:37 AM, and 199/104 mm/Hg at 11:12 AM; and PCT #10 documented the patient’s blood pressure was 194/102 mm/Hg at 9:05 AM. There was no documented evidence that the PCTs notified an RN of the patient’s out-of-range blood pressures. A “Treatment Sheet” for Patient #7 dated 12/09/2025 revealed RN #3 documented the patient’s blood pressure was 217/121 mm/Hg at 7:41 AM; PCT #9 documented 229/121 mm/Hg at 8:32 AM; and PCT #6 documented blood pressures of 201/103 mm/Hg at 9:00 AM, 201/99 mm/Hg at 9:30 AM, 200/106 mm/Hg at 10:00 AM, 220/174 mm/Hg at 10:30 AM, and 216/116 mm/Hg at 10:57 AM. There was no documented evidence that the PCTs notified an RN, or that the RN notified the provider of the out-of-range vital signs. A “Treatment Sheet” for Patient #7 dated 12/16/2025 revealed RN #4 documented the patient’s blood pressure was 197/96 mm/Hg at 8:21 AM and 187/92 mm/Hg at 8:33 AM, and PCT #11 documented the patient’s blood pressure was 186/100 mm/Hg at 11:00 AM and 197/101 mm/Hg at 12:04 PM. There was no documented evidence that the PCTs notified an RN, or that the RN notified the provider of the patient’s out-of-range blood pressures. A “Treatment Sheet” for Patient #7 dated 12/22/2025 revealed that PCT #12 documented the patient’s blood pressure was 221/121 mm/Hg at 7:37 AM, 218/115 mm/Hg at 8:36 AM, 208/110 mm/Hg at 10:34 AM, 223/112 mm/Hg at 11:03 AM, 213/122 mm/Hg at 11:34 AM, and 234/122 mm/Hg at 11:39 AM. Per the 12/22/2025 Treatment Sheet, PCT #11 documented that Patient #7’s blood pressure was 234/131 mm/Hg at 8 :00 AM, 211/108 mm/Hg at 9:00 AM, 211/108 mm/Hg at 9:30 AM, and 217/109 mm/Hg at 10:00 AM. There was no documented evidence that the PCTs notified an RN of the patient’s out-of-range blood pressures. A “Treatment Sheet” for Patient #7 dated 12/24/2025 showed that PCT #8 documented the patient’s blood pressure was 197/97 mm/Hg at 7:36 AM, and PCT #13 documented the patient’s blood pressure was 188/104 mm/Hg at 9:08 AM. There was no documented evidence that the PCTs notified an RN of the patient’s out-of-range blood pressure. On 01/09/2026 at 12:28 PM, PCT #9 stated that the PCTs monitored to ensure that a patient’s blood pressure was in range for the individual patient and stated that some patients’ vital signs were always going to be out of range. PCT #9 stated that the dialysis machine’s alarm range and the normal blood pressure was between 90 and 180 mm/Hg systolic and 50 to100 mm/Hg diastolic and a normal heart rate was 50 to 100 bpm. The PCT stated that when a patient’s vital signs were out of range, the PCT was supposed to notify an RN and proceed from there. According to PCT #9, staff were also supposed to document RN notifications but stated it did not always happen. On 01/09/2026 at 2:00 PM, RN # 2 indicated that PCTs should report to an RN if a patient’s vital signs are out of range. The RN stated that out of range would be considered a systolic blood pressure higher than 180 mm/Hg or less than 100 mm/Hg, a diastolic blood pressure less than 50 mm/Hg, or a heart rate higher than 100 bpm or less than 50 bpm. The RN stated that an RN should assess the patient and determine whether any interventions were necessary and document the assessment and blood pressure rechecks. Per RN #2, the provider would be notified for sustained systolic blood pressure reading above 200 mm/Hg and that any provider notification would be documented. During an interview on 01/07/2026 at 1:38 PM, the Charge Nurse (CN) revealed that facility practice was for the PCTs to notify an RN of out-of-range vital signs for initial readings and any worsening of the vital signs. Per the CN, a PCT would not notify the RN of every out-of-range reading, as long as the patient’s vital signs were not worsening. The CN stated that the normal facility practice was to notify the provider if the patient had a systolic blood pressure reading of greater than 180 mm/Hg. The CN stated that any notification to an RN or a provider should be documented. The CN stated that the PCTs were very good at notifying an RN when needed but noted that the documentation was missing. During an interview on 01/07/2026 at 2:05 PM, the Director of Operations (DO) revealed that per company policy the staff needed to notify an RN for every out-of-range vital sign reading, unless there were special parameters or orders for the patient. During an interview on 01/09/2026 at 1:04 PM, the Medical Director revealed that any notification should be documented. The Medical Director stated that there was constant communication, and suspected notification was a documentation issue.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 50873 Based on record review, interview and facility document and policy review, the facility failed to ensure dialysis prescriptions were administered as ordered for six (Patients #1, #3, #4, #5, #6, and #7) of seven sampled patients. Findings included: 1. A facility policy titled, “Patient Assessment and Monitoring,” published 05/01/2023, indicated that when monitoring patients, staff should “Check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow.” A “Treatment Sheet” for Patient #4 dated 12/23/2025 revealed the patient had dialysis orders for a blood flow rate (BFR) of 400. The Treatment Sheet revealed staff documented that the patient’s dialysis machine was set for a BFR of 300 from 12:41 PM until 1:38 PM on 12/23/2025. There was no documented evidence of a rationale for the deviation from the patient’s dialysis prescription. A “Treatment Sheet” for Patient #5 dated 12/30/2025 revealed the patient had dialysis orders for a BFR of 450. According to the Treatment Sheet, staff documented that the patient’s dialysis machine was set for a BFR of 400 from 6:02 AM until 9:32 AM on 12/30/2025. There was no documented evidence of a rationale for the deviation from the patient’s dialysis prescription. A “Treatment Sheet” for Patient #6 dated 01/05/2026 revealed the patient had dialysis orders for a BFR of 300. According to the Treatment Sheet, staff documented that the patient’s machine was set for a BFR of 350 from 1:47 PM until 4:15 PM on 01/05/2026. There was no documented evidence of a rationale for the deviation from the patient’s dialysis prescription. Patient #7’s “Treatment Sheet” dated 12/09/2025, 12/16/2025, and 12/24/2025 revealed the patient had dialysis orders for a BFR of 400. The 12/09/2025 Treatment Sheet revealed staff documented that the patient’s machine was set for a BFR of 350 from 8:31 AM until 10:30 AM. Patient #7’s “Treatment Sheet” dated 12/16/2025 revealed staff documented that the patient’s machine was set for a BFR of 350 from 8:33 AM until 12:30 PM. In addition, Patient #7’s Treatment Sheet dated 12/24/2025 revealed staff documented that the patient’s dialysis machine was set for a BFR of 350 from 8:31 AM until 10:54 AM. There was no documented evidence of a rationale for the deviation from the patient’s dialysis prescription. On 01/09/2026 at 2:00 PM, Registered Nurse (RN) #2 stated that staff should document any time they ran a treatment at a BFR other than the prescribed rate. On 01/09/2026 at 1:04 PM, the Medical Director revealed the facility’s expectation was for BFR deviations to be documented with a rationale. 2. A. Patient #1’s “Initial/Annual Standing Orders - Outpatient Hemodialysis Orders” signed by a physician on 10/16/2025 revealed an order for “Management of Hypertension” that indicated “Hypertension: Administer Clonidine 0.1mg [milligrams] x 1 tab [one tablet] PO [by mouth]. May repeat after 1 hours if BP [blood pressure] remains elevated > [greater than] 200 [millimeters of mercury (mm/Hg)] systolic [top number of a blood pressure reading] and /or >105 diastolic [bottom number of a blood pressure reading]. Assess dry weight and notify MD [medical doctor].” The order did not specify blood pressure parameters for administering the first dose of clonidine. A “Treatment Sheet” for Patient #1 dated 12/22/2025 revealed that Registered Nurse (RN) #3 documented that the patient’s blood pressure was 208/110 mm/Hg while sitting and 202/109 mm/Hg while standing at 6:11 AM and 190/115 mm/Hg at 6:24 AM, and RN #2 documented the patient’s blood pressure was 183/93 mm/Hg at 7:02 AM. There was no documented evidence that staff administered PRN clonidine. Patient #1’s “Treatment Sheet” dated 01/03/2026 revealed that RN #3 documented that the patient’s blood pressure was 183/99 mm/Hg at 6:30 AM, and RN #5 documented the patient’s blood pressure was 197/109 mm/Hg at 7:30 AM. There was no documented evidence that staff administered PRN clonidine. 2. B. Patient #3’s “Initial/Annual Standing Orders - Outpatient Hemodialysis Orders” signed by a physician on 04/07/2025 revealed an order for “Management of Hypertension” that indicated “Hypertension: Administer Clonidine 0.1mg [milligrams] x 1 tab [one tablet] PO [by mouth]. May repeat after 1 hours if BP [blood pressure] remains elevated > [greater than] 200 [millimeters of mercury (mm/Hg)] systolic [top number of a blood pressure reading] and /or >105 diastolic [bottom number of a blood pressure reading]. Assess dry weight and notify MD [medical doctor].” The order did not specify blood pressure parameters for administering the first dose of clonidine. Patient #3’s physician “Orders Summary Report” also revealed an order started on 12/02/2025 for clonidine 0.1 mg by mouth during dialysis as needed with an order to repeat one time for a systolic blood pressure greater than 180. Again, the order did not specify blood pressure parameters for administering the first dose of clonidine. A “Treatment Sheet” for Patient #3 dated 12/11/2025 revealed Registered Nurse (RN) #2 documented that the patient’s blood pressure was 168/106 mm/Hg while sitting and 158/119 mm/Hg standing at 6:51 AM, and that the patient’s blood pressure was 182/126 mm/Hg at 7:14 AM, and 245/162 mm/Hg at 11:10 AM. There was no documented evidence that staff administered PRN clonidine to the patient. A “Treatment Sheet” for Patient #3 dated 12/18/2025 revealed RN #5 documented that the patient’s blood pressure was 198/123 mm/Hg at 12:41 PM and 250/143 mm/Hg at 2:00 PM, and RN #16 documented that the patient’s blood pressure was 228/134 mm/Hg at 1:34 PM. There was no documented evidence that staff administered PRN clonidine. Per the Treatment Sheet, at 2:30 PM on 12/18/2025, RN #5 documented the patient’s blood pressure was 240/136 mm/Hg and a dose of PRN clonidine was given. According to the Treatment Sheet, one hour later, at 3:30 PM, Patient Care Technician (PCT) #7 documented that the RN was notified that Patient #3’s blood pressure was 229/132. There was no documented evidence that a second dose of clonidine was given per order. A “Treatment Sheet” for Patient #3 dated 12/20/2025 revealed that RN #5 documented the patient’s blood pressure was 198/129 mm/Hg at 12:24 PM, 244/135 mm/Hg at 4:00 PM, and 233/125 mm/Hg at 4:26 PM. There was no documented evidence that PRN clonidine was administered to the patient. A “Treatment Sheet” for Patient #3 dated 12/22/2025 revealed RN #2 documented that the patient’s blood pressure was 181/118 mm/Hg at 1:00 PM, and RN #3 documented that the patient’s blood pressure was 225/127 mm/Hg at 4:00 PM and 221/122 mm/Hg while sitting and 221/124 mm/Hg while standing 4:02 PM. There was no documented evidence that staff administered PRN clonidine for the out-of-range blood pressure readings. A “Treatment Sheet” for Patient #3 dated 12/29/2025 revealed Registered Nurse (RN) #2 documented that the patient’s blood pressure was 201/124 mm/Hg at 12:40 PM, 187/170 mm/Hg at 12:51 PM, and 205/126 mm/Hg at 1:00 PM; and RN #4 documented the patient’s blood pressure was 218/128 mm/Hg at 3:55 PM and 219/124 mm/Hg while sitting and 187/113 while standing at 3:56 PM. There was no documented evidence that staff administered PRN clonidine. 2. C. 2. Patient #7’s “Initial/Annual Standing Orders - Outpatient Hemodialysis Orders” signed by a physician on 09/09/2025, revealed an order for “Management of Hypertension” that indicated “Hypertension: Administer Clonidine 0.1mg [milligrams] x 1 tab [one tablet] PO [by mouth]. May repeat after 1 hours if BP [blood pressure] remains elevated > [greater than] 200 [millimeters of mercury (mm/Hg)] systolic [top number of a blood pressure reading] and /or >105 diastolic [bottom number of a blood pressure reading]. Assess dry weight and notify MD [medical doctor].” The order did not specify blood pressure parameters for administering the first dose of clonidine. A “Treatment Sheet” for Patient #7 dated 12/09/2025 revealed Registered Nurse (RN) #3 documented that the patient’s blood pressure was 217/121 mm/Hg at 7:41 AM. There was no documented evidence that staff administered PRN clonidine. A “Treatment Sheet” for Patient #7 dated 12/16/2025 revealed RN #4 documented that the patient’s blood pressure was 197/96 mm/Hg at 8:21 AM and 187/92 mm/Hg at 8:33 AM. There was no documented evidence that staff administered PRN clonidine. On 01/09/2026 at 2:00 PM, RN #2 stated that the facility practice was to verify a blood pressure reading of greater than 180 mmHg, and if it remained elevated for an hour, the RN administered a PRN clonidine tablet. On 01/07/2026 at 2:05 PM, the Charge Nurse (CN) stated that the facility practice was to dialyze a patient with an elevated blood pressure reading for an hour to see if the blood pressure came down with treatment before giving PRN clonidine. During a follow-up interview on 01/08/2026 at 1:00 PM, the CN stated again that the facility practice was to wait one hour after starting treatment prior to giving PRN clonidine for elevated blood pressures. Regarding a policy or procedure outlining the expectation to wait for an hour, the CN stated, “I don’t know that there is one.” On 01/09/2026 at 1:04 PM, the Medical Director revealed that PRN clonidine should be administered when an elevated blood pressure reading was obtained and staff should not wait an hour into treatment prior to taking action. The Medical Director stated that the exception would be if a patient had individual special attention orders that stated otherwise.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 50873 Based on observation, interview, and facility policy review, the facility failed to ensure Patient Care Technician (PCT) #8 assessed the patency of a patient’s arteriovenous fistula or graft (a dialysis access, which is a surgically created connection between an artery and a vein) prior to accessing the graft during 1 of 2 observations of cannulation (inserting a needle into the graft). Findings included: A facility policy titled, “Patient Assessment and Monitoring,” published 05/01/2023, indicated that pre-treatment assessment data included, “Evaluate the patient’s access per policy: ASK: complaints of pain, numbness, tingling, coldness and tenderness, fever. Look. Listen. Feel.” A facility policy titled “Access Assessment and Cannulation” published 05/05/2025 indicated, “The purpose of this procedure is to provide guidance for assessing patency and placement of needles in an AV [arteriovenous] Fistula or AV graft to obtain access to the circulatory system for hemodialysis.” The policy revealed when assessing the vascular access, “Staff/patients/care partners who have been trained to auscultate vascular accesses should listen with a stethoscope to the entire length of the access for changes in the sound of the bruit - a normal low-pitched bruit should be present.” On 01/06/2026 at 10:43 AM, Patient Care Technician (PCT) #8 was observed initiating dialysis at Treatment Station #7 for a patient with an AV fistula or graft. The PCT was observed to clean the patient’s access site with soap and water, apply antiseptic to the patient’s access, and then cannulate the access. The observation revealed PCT #8 did not auscultate the dialysis access prior to cannulation. During an interview on 01/06/2026 at 3:17 PM, PCT #8 stated that assessing the dialysis access prior to cannulation included, “Feel the thrill, which is like a pulsing and then listen for the bruit, which if the access is clogged, you won’t hear it.” The PCT revealed that they did not auscultate the access prior to initiation of dialysis at Treatment Station #7. The PCT stated that they usually performed auscultation but “skipped over” that step. On 01/06/2026 at 4:00 PM, the Charge Nurse revealed that the facility’s expectation was for staff to auscultate all dialysis accesses prior to cannulation. On 01/09/2026 at 1:04 PM, the Medical Director also revealed that the facility’s expectation was for every dialysis access to be auscultated prior to cannulation.”